Often overshadowed by asthma and COPD, hospital admissions for bronchiectasis are estimated to cost the US healthcare system as much as $1.4 billion annually. The use of airway clearance therapy can be a key part of the daily management of the disease.
By Cassandra Perez
Bronchiectasis is an incurable lung condition characterized by an abnormal stretching and enlargement of the bronchi and bronchioles, the larger airways of the lungs.1 The effective treatment of this condition can better a patient’s quality of life and improve associated symptoms, and respiratory therapists (RTs) can play an integral role in the care of bronchiectasis patients. This article will cover the latest research and clinical practices related to bronchiectasis, the therapeutic benefits of airway clearance and the overall goals of therapy for patients, and how new technology is improving quality of care for patients.
Clinical Guidelines
The treatment of bronchiectasis focuses on controlling infections and secretions, relieving obstructions in the airway, sometimes surgically removing affected portions of the lung, embolization, and preventing complications.2 Early and effective treatment can significantly reduce complications, such as low blood oxygen levels and respiratory failure.2 Patients with bronchiectasis who have a chronic productive cough and/or evidence of mucus plugging on HRCT scanning should be taught airway clearance techniques by a clinician.3 The duration and frequency of the airway clearance technique should be specific to the needs of the individual, but generally it should be performed for 20 to 30 minutes once or twice daily.3
The following are airway clearance techniques available for the treatment of bronchiectasis: cough and huffing; postural drainage and percussion/vibrations Active Cycle of Breathing (ACBT); Autogenic Drainage (AD); Positive Expiratory Pressure (PEP); Oscillating PEP; and High Frequency Chest Wall Oscillation (HFCWO). All techniques should be adapted to suit the personal needs of a patient, and clinicians should consider the underlying pathology when prescribing a treatment plan.3
Therapeutic Benefits
Airway clearance therapy can yield positive benefits for bronchiectasis patients. “Airway clearance therapy is a key part of daily management of bronchiectasis, maximizing the opportunity to clear secretions and minimize symptoms of coughing throughout the course of a day,” explained Annemarie Lee, PhD, a lecturer in the department of rehabilitation, nutrition, and sport, at the School of Allied Health. “These effects help to reduce an individual person’s risk of chest infections and maximize the chance to maintain an effective exercise and activity routine which will promote a strong respiratory reserve.”
The prevention of infection is a key goal of airway clearance therapy as it can exacerbate bronchiectasis and endanger a person’s health. Tom Newton, RCP, RRT, AE-C, respiratory therapist for the outpatient Pediatric Pulmonary and Cystic Fibrosis clinic at Miller Children’s & Women’s Hospital Long Beach, explained, “If the clearance of mucus in the patient with bronchiectasis is not performed, the patient puts themselves at risk for further infections and worsening of their bronchiectasis. This can lead to further loss of lung function, increased hospitalizations, the need to wear oxygen even at home, and the possible need for lung transplantation in the future.”
In addition to preventing new infections, airway management is also important in the mobilization of excessive secretions, says Chrishuna R Vasser, BS, RRT, a respiratory therapist at AMG Specialty Hospital. “Thick viscous secretions are problematic in the lungs of bronchiectasis patients. These secretions create mucus plugs and adhere to the walls of the bronchi and cause airway obstruction,” said Vasser. “Excessive secretions with pus formation cause a chronic, persistent, productive cough that is a primary symptom of bronchiectasis. Airway management will be important in reducing the amount of secretions retained in the lungs and improve lung volumes.”
According to Theresa McGauley-Keaney, MPA, RRT, a respiratory care specialist and program monitor and trainer in disability & community services at Commonwealth Medicine, University of Massachusetts Medical School, stagnant mucus can cause damage to airways and lung parenchyma by spurring inflammation, obstructing airways, and facilitating pathogenic infections. As such, McGauley-Keaney said, “Airway clearance is required as part of a multipronged treatment approach to limiting damage, increasing subjective quality of life by decreasing cough frequency and ultimately reducing morbidly and prolonging life.”
Goals of Therapy
From improving quality of life to enhancing lung function, there are a number of therapeutic goals healthcare professionals strive to achieve when opting to administer airway clearance therapy. The overall goals of therapy are to improve symptoms, reduce complications, control exacerbations, and to reduce morbidity and mortality.4 In addition, the management of underlying conditions, which may include the use of intravenous immunoglobulin or intravenous alpha-1 antitrypsin (AAT) therapy, is essential to the overall treatment.4
“For people with bronchiectasis, the key goals of airway clearance therapy are to maximize sputum clearance,” Lee said. “As a result of this, improvement in quality of life, improvement in lung function, reduction in symptoms of coughing, fatigue and breathlessness, and reducing the frequency of acute infections may be achieved. By minimizing the frequency of acute infections, the morbidity linked to bronchiectasis may be reduced.”
Airway clearance therapy is also important in effectively managing bronchiectasis, said Vasser. “The overall goals for disease management include optimizing lung function by resolving inflammation, controlling infection, and airway clearance, explained Vasser. “Maintaining a clear airway will be evidenced by improvement in the color, consistency, quantity and odor of sputum production. Improvement in the quality of life will be evidenced by reduced exacerbations, increased physical activity, and improvement in pulmonary hyperinflation.”
An added goal of airway clearance is to keep mucus moving, which starts at diagnosis, said Newton, who added that it is imperative to stress the importance of therapeutic adherence, especially in pediatric patients.
Chet Sievert, director of regulatory and clinical affairs at Electromed, said, “Certainly clearing the airways of excess mucus is critical; however, the clinical outcome goal is to reduce exacerbation rates associated with bronchiectasis such as recurrent hospitalizations and frequent pneumonias. Importantly, achieving the clinical goal results in a significant improvement in the patient’s quality of life.”
Generally, the primary goal of this therapy is subjective and patient-specific depending on the underlying cause of the bronchiectasis, according to McGauley-Keaney. “Airway clearance pertaining to bronchiectasis as a broad category is mainly for mobilization and removal of secretions always with the goal to prevent atelectasis, optimize gas exchange, and stave off infection,” she said.
Role of the RT in Patient Care
From patient monitoring to treatment assessment, RTs play an essential role in the care of bronchiectasis patients. “The role of the RT on a bronchiectasis care team is to employ strict bronchopulmonary hygiene efficiently and consistently [and] assess response to therapies by reviewing X-rays, lab work, and monitoring sputum production,” said Vasser. “[RTs also administer] aerosolized nebulizers, mucolytics, and antibiotics [that] will be important in reducing inflammation and smoothing the bronchial lining for easy facilitation of secretions.” She added that the RT will monitor overall response to care by witnessing improved patient outcomes.
Newton says the role of the RT in the care of this patient population has expanded in recent years. “There are now more inhaled medications, with more choices of delivery devices. We have more choices for airway clearance that we need to know, understand, and teach,” said Newton. “The healthcare provider has to be aware of and have knowledge of all of the different airway clearance devices that are on the market. We have to make sure our doctors are kept abreast of the new technology and the therapies we are teaching our patients.”
The tailoring of treatment based on each patient’s unique needs is crucial in the treatment of bronchiectasis patients, and the RT plays a vital role in personalizing care.
“The RT is the expert in airway clearance and works closely with the patient to identify which technique or combination of techniques may work best for each individual. Within this role, they identify what specific barriers a patient may have to performing effective airway clearance therapy and are in a position to refer to other team members for management of these barriers,” according to Lee. “Teaching a patient to recognize the early signs of infection and implementing an action plan is an important part of self-management and an RT is in a critical position to facilitate this process.”
In addition, Lee explained that an RT can help identify whether a patient needs adjustment to inhalation therapy to facilitate their airway clearance routine, provide guidance and recommendations in exercise therapy, and give tips in conjunction with a dietician or nutritionist for proper hydration. Also, determining several factors, including a patient’s comorbidities, the presence of sinus symptoms, and incontinence, are an important of an RT’s assessment because they may influence which airway clearance technique is appropriate.
“Respiratory therapists have advanced skills and knowledge in airway pathology and gas flow physics. Providing therapy modalities first hand and in succession allows the RT to observe nuances, troubleshoot, document, and gain critical knowledge. This experience makes the RT a critical voice in the care team,” said McGauley-Keaney.
On the Market
A number of products available on the market can aid healthcare professionals in administering airway clearance therapy to bronchiectasis patients. Several products available for sale are designed specifically to deliver HFCWO to facilitate airway clearance, and this technology consists of a wearable vest that surrounds an inflatable air bladder. One such HFCWO product is the Vest Airway Clearance System from Hill-Rom, which is fifth generation HFCWO technology that aims to provide effective airway clearance therapy to mobilize mucus retained in the lungs. The Vest system features multiple programming options for prescription flexibility, the ability to pause to aid in deep breathing, quiet operation, and multiple garment options, styles, and sizes.
The Vest Airway Clearance System consists of an inflatable garment attached to an Air Pulse Generator that rapidly inflates and deflates the garment, according to Nancy Linda, national education manager for Hill-Rom. She explained, “This causes the chest wall to be gently compressed and released, which creates airflow within the lungs. This process moves the mucus toward the large airways where it can be cleared by coughing or suctioning.”
The SmartVest SQL Airway Clearance System delivers HFCWO therapy to promote airway clearance and enhance bronchial drainage for patients with compromised airway clearance, including excess mucus production and retention, explained Electromed’s Sievert. The system has several clinically significant features, but Sievert said the SmartVest’s patented open system with active inflate – active deflate that allows the pressure inside the SmartVest to almost completely depressurize in between oscillations is the most clinically important. He said,”[This] is associated with greater comfort and makes it easier to breathe during treatment. Greater comfort leads to greater treatment compliance and thereby is more effective for the patient.”
The prevention of infection is a significant component of bronchiectasis treatment, and Sievert says the SmartVest System delivers HFCWO, which has been clinically proven to significantly reduce mucus build-up in the lungs. “Significantly improving the patient’s ability to loosen and expectorate pathogenic loaded mucus prevents the bacterial counts from rising to the level of an infection,” said Sievert.
The AffloVest, which is manufactured by International Biophysics Corp, is a portable, battery operated HFCWO vest that is fully mobile during use. According to Dana Kolflat, director of marketing at International Biophysics, “The AffloVest promotes airway clearance and lung secretion mobilization in physician prescribed treatment of respiratory diseases like bronchiectasis. [The device] is a preventative therapy that gives patients a device that they can easily use at home or anywhere, which could help prevent mucus buildup, subsequent lung infections, hospitalizations, and lower readmissions.”
The AffloVest has a digital controller that can monitor compliance and features three modes of oscillation therapy (percussion, vibration, and drainage) that help the device to more accurately mimic chest physical therapy, explained Kolflat. In addition, the device has eight oscillating motors that create eight individual pressure waveforms to help produce shearing forces in the lungs to help mobilize secretions. With a full range of sizes and features that aim to provide comfort as well as customizable patient treatment plans, Kolflat said, “The goal of this oscillation therapy is to clear your patient’s airways to reduce the number of chronic chest infections, and thereby help manage bronchiectasis better.”
RespirTech manufactures the inCourage System, a noninvasive vest therapy system that is designed to clear excess mucus from the airways and lungs. The inCourage System also offers an active venting feature that allows users to take a deep, comfortable breath during therapy, explained Bob Buehler, chief commercial officer of RespirTech, and better comfort may make it easier to adhere to prescribed therapy sessions and lead to better patient outcomes. The system also uses triangle waveform technology that delivers a brief, CPT-like thump to the chest compared to the squeezing pressure of sine waveform vest systems.
“Our outcomes database will continue to follow thousands of bronchiectasis patients and demonstrate the value of inCourage System use in maintaining or improving their health and quality of life,” Buehler said, “RespirTech will continue to enhance the inCourage System to make it easier and more convenient to use.”
Airway Clearance and Nebulized Medicine
The PercussiveNEB from Vortran Medical is a handheld device used to mobilize secretions and is another option for the treatment of bronchiectasis. “Our patients who use the PercussiveNEB use it mainly for the valuable removal of excess secretions produced. The PercussiveNEB allows for patients to use a handheld device to deliver percussive vibratory therapy to assist in the mobilization of the excess secretions,” according to Jeremy LaPlante, vice president of global sales & marketing for Vortran Medical. “It delivers nebulized medicine on the inhalation phase and then creates a vibratory percussion effect when the patient exhales to promote better airway clearance.”
The PercussiveNEB offers a percussive effect on exhalation that assists in the breaking up and mobilization of sputum plugs that form on the walls of the lungs in the patient, explains LaPlante. He said, “Using this device helps break those off the walls so that they can be coughed out by the patient and allow them to recruit more oxygen to their alveoli.”
Vortran Medical also plans to introduce a new version of the PercussiveNEB. “It will operate similar to our current model but require less airflow to create the same percussive effect. We are excited to introduce this new model as we predict it will be a great modality to be used by home care patients,” said LaPlante
‘Clearing the Air’ in Bronchiectasis
Future developments in airway clearance technology may focus on features to enhance patient comfort, convenience, and adherence. “The trends we are seeing in airway clearance devices are all focused on ensuring the patient continues to do their prescribed therapy when they are home. We are seeing a reduction in size and weight as well as technology advancements in multitherapy devices and data connectivity,” said Leah Noaeill, senior global portfolio manager at Hill-Rom. “Over the next few years we will [also] see airway clearance devices, which can inform the healthcare team regarding their patient’s therapy adherence and lung health to help create a treatment plan tailored to patient’s lifestyles.”
“We would expect to see more advances in effective airway clearance technologies hand in hand with features that provide increased quality of life,” added Kolflat.
Products that offer in-home treatment may be a vital component of future treatment devices and systems. Jeremy LaPlante, vice president of global sales & marketing for Vortran Medical, said, “I see many companies like Vortran Medical looking for technology to introduce that allows for more patients to be treated at home. The costs of healthcare continues to increase and it is in the best interest of this industry to find ways for patients to use similar devices at home rather than in the hospital.”
Vasser echoed that sentiment and said future devices should enable convenient treatment. “I am an advocate of telemedicine. New advancements for the future will include more ‘smart devices’ that will allow the patient to be managed at home,” said Vasser. “This will ultimately lead to reduced infections and allow better control of healthcare costs.”
The use of technology can also help improve connectivity among a patient’s care team. “The use of electronic documentation enables us to download data from mechanical ventilators and perhaps one day from HFCWO vests and…make it into a useable format for analysis of effectiveness and inform corrective action,” said McGauley-Keaney. Additionally, she says she would like to think, “Moore’s Law will continue to apply to all medical technology. The smaller, more effective and more convenient OPEP, HFCWO, or IPV clearance technology becomes, the better off those who suffer from bronchiectasis will be.”
“Current therapies as well as new therapies need to focus on the cost benefit, which includes decreasing hospitalizations and readmissions, emergency department visits, and the frequency of antibiotic usage. Working together to ensure a therapy is effective as well as ensuring a lower total cost of healthcare for the patient and third party payers are important attributes of any new advancement in airway clearance,” said Sievert of Electromed.
Overall, adherence and patient education is key improve patient outcomes. “Bronchiectasis is an irreversible lung disorder. Patient education is very important in keeping patients out of the hospital,” said Vasser. “I would encourage any patient to not allow this disease to dictate how you live. Learn to live the best life effectively while managing the disease.”
“Depending on the patient, their disease state, and their willingness/ability to put forth the effort needed, all [airway clearance] types can be equally effective,” said Newton. “It all comes down to adherence. We can provide the best technology, be an expert, and teach all the airway clearance techniques, but it’s up to the patient to use it. In the end, we are all cheerleaders trying to motivate and give our patients the best chance at a long and fruitful life.” RT
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